Section 23Hearing Aid and Audiometric Evaluations 23 23.1 Enrollment...................................................... 23-2 23.1.1 Medicaid Managed Care Enrollment............................... 23-2 23.2 Reimbursement.................................................. 23-2 23.3 Benefits....................................................... 23-2 23.3.1 Hearing Screenings........................................... 23-3 23.3.1.1 Newborn Hearing Screening................................ 23-3 23.3.1.2 Initial Test at Birth....................................... 23-3 23.3.1.3 Outpatient Hearing Screening and Diagnostic Testing for Children..... 23-3 23.3.1.4 Three Years of Age and Younger............................. 23-4 23.3.1.5 Three Through 20 Years of Age.............................. 23-4 23.3.1.6 Abnormal Screening Results................................ 23-4 23.3.1.7 Adults Hearing Screening 21 Years of Age and Older.............. 23-4 23.3.1.8 Hearing Referrals....................................... 23-4 23.3.2 Hearing Aid Instrument........................................ 23-4 23.3.2.1 Warranty.............................................. 23-4 23.3.2.2 30-Day Trial Period...................................... 23-4 23.3.2.3 Fitting and Dispensing Visit................................ 23-5 23.3.2.4 First Revisit............................................ 23-5 23.3.2.5 Second Revisit......................................... 23-5 23.3.3 Audiological Testing.......................................... 23-6 23.4 Limitations and Exclusions.......................................... 23-7 23.5 Documentation Requirements........................................ 23-7 23.6 Client Eligibility.................................................. 23-7 23.7 Claims Information................................................ 23-7 23.7.1 Claim Filing Resources........................................ 23-8 CPT only copyright 2007 American Medical Association. All rights reserved.
Section 23 23.1 Enrollment To enroll in the Texas Medicaid Program, hearing aid professionals (physicians, audiologists, and fitters and dispensers) who provide hearing evaluations or fitting and dispensing services must be licensed by the licensing board of their profession to practice in the state where the service is performed. Hearing aid providers are only eligible to enroll as individuals and facilities. Additionally, audiologists not wanting to enroll as a hearing aid provider are allowed to enroll separately as audiologists. Providers cannot be enrolled if their license is due to expire within 30 days. A current license must be submitted. Important: All providers are required to read and comply with Section 1, Provider Enrollment and Responsibilities. In addition to required compliance with all requirements specific to the Texas Medicaid Program, it is a violation of Texas Medicaid Program rules when a provider fails to provide health-care services or items to Medicaid clients in accordance with accepted medical community standards and standards that govern occupations, as explained in Title 1 Texas Administrative Code (TAC) 371.1617(a)(6)(A). Accordingly, in addition to being subject to sanctions for failure to comply with the requirements that are specific to the Texas Medicaid Program, providers can also be subject to Texas Medicaid Program sanctions for failure, at all times, to deliver health-care items and services to Medicaid clients in full accordance with all applicable licensure and certification requirements including, without limitation, those related to documentation and record maintenance. Refer to: Provider Enrollment on page 1-2 for more information on enrollment procedures. 23.1.1 Medicaid Managed Care Enrollment Hearing aid providers must enroll with Medicaid Managed Care to be reimbursed for services provided to Medicaid Managed Care clients. 23.2 Reimbursement Hearing aids and audiometric services are reimbursed in accordance with 1 TAC 355.8141. Hearing evaluations and the first and second revisits are reimbursed according to the maximum allowable fee. Procedure codes R-99211 and R-99212 should be billed for the first and second revisits, respectively. Reimbursement for ear molds and the fitting and dispensing fee is limited to the established maximum fee. Hearing aid procedures indicated with "" (Manually Review) must be submitted with the Manufacturer's Suggested Retail Price (MSRP) in the Comments field of the claim. If the MSRP is not included in the comments field on the original submission, the claim will be denied. Providers will be required to submit their request as an appeal, and must include an invoice validating the cost of the instrument. The maximum allowable fee for the hearing aid instrument includes: Acquisition cost of the hearing aid (the actual cost or net cost of the hearing aid after any discounts have been deducted). Manufacturer s postage and handling charges. All necessary tubing, cords, and connectors. Bone conduction headbands. Telephone coils. Compression circuits. Contralateral Routing of Offside Signal (CROS)/Bilateral Contralateral Routing of Offside Signal (BICROS) features. Instructions for care and use. One-month supply of batteries. Charges for hearing aid components must be verified by the manufacturer s invoice and price lists. The fitting and dispensing fee includes the postfitting check of the hearing aid within five weeks after the dispensing date. Note: Charges to the client for covered services constitute a breach of the Medicaid contract. Refer to: Reimbursement Methodology on page 2-2 for more information on reimbursement. Billing Clients on page 1-10 for more information. Fee schedules for services in this chapter are available on the TMHP website at www.tmhp.com/file%20library /file%20library/fee%20schedules. 23.3 Benefits Hearing aid services, including hearing aid instruments, are considered for reimbursement when they are medically necessary. Benefits for hearing aid services are determined by statutory and fiscal limitations. For clients 21 years of age and older, hearing aid services are benefits of the Texas Medicaid Program. For Medicaid clients 20 years of age and younger, hearing aid services are available through the Department of State Health Services (DSHS) Program for Amplification for Children of Texas (PACT). An appropriate hearing screening is a mandatory part of each medical check up. When suspicion or indication of a hearing problem occurs, the client should be referred to an enrolled PACT provider. For a list of PACT providers, visit the PACT website at www.dshs.state.tx.us/audio /program.shtm or write to: DSHS Program for Amplification for Children of Texas (PACT) 1100 West 49th Street Austin, TX 78756-3199 1-512-458-7724 23 2 CPT only copyright 2007 American Medical Association. All rights reserved.
Hearing Aid and Audiometric Evaluations 23.3.1 Hearing Screenings Audiometry is the testing of a person s ability to hear various sound frequencies and is performed with the use of electronic equipment. Audiometry is used to identify and diagnose hearing loss. Otoacoustic emissions (OAE) or auditory brainstem response (ABR) audiometry are benefits of the Texas Medicaid Program for infants, children, and adults who cannot be tested by conventional audiometry. 23.3.1.1 Newborn Hearing Screening Health Safety Code, Chapter 47, Vernon s Texas Codes Annotated mandates that a newborn hearing screening occur at the birthing facility before hospital discharge. The hospital is responsible for the purchase of equipment, training of personnel, screening of the newborns, certification of the program according to DSHS standards, and notification to the provider, parents, and DSHS of screening results. OAE or ABR audiometry are used to screen for newborn hearing and may be performed as early as a few hours after birth when completed by a licensed audiologist. There is no additional Medicaid reimbursement for the newborn hearing screening because the procedure is part of the newborn hospital diagnosis related group (DRG) payment. Hospitals must use procedure code K-09547 to report this newborn hearing screen on the UB-04 CMS-1450 claim form. This facility-based screening also meets the physician s required component for hearing screening in the inpatient newborn Texas Health Steps (THSteps) check up. The physician must ensure that the hearing screening is completed before discharging the newborn or, when the birthing facility is exempt under the law, that there is an appropriate referral for a hearing screening to a birthing facility participating in the newborn hearing screening program. The physician must discuss the screening results with the parents, especially if the hearing screening results are abnormal, and order an appropriate referral for further diagnostic testing. If the results are abnormal, the parent s or legal guardian s consent must be obtained to send information to DSHS for tracking and follow-up purposes. If a physician has any concerns about this process, the physician should contact the hospital administrator or the DSHS Audiology Services Program at 1-512-458-7724. 23.3.1.2 Initial Test at Birth The provider must do the following: Verify that the parents received the results of the hearing screen at the birthing facility. Check for obvious physical abnormalities. Supply a hearing checklist for parents and instructions on its use (this checklist is discussed at the first inoffice THSteps medical check up). Provide a referral for further diagnostic audiological testing for an infant with abnormal screening results or who is at high-risk for hearing impairment. If the Infant is admitted to a birthing facility, the facility where the birth occurs must offer newborn hearing screenings through a program mandated by the Texas State Legislature and certified by the Texas Department of Health. Procedures for newborn hearing screenings provided during the birth admission are considered part of the newborn delivery payment to the facility and are not considered for reimbursement as separate procedures. If the infant is not admitted to a birthing facility or is born outside of a birthing facility, procedures for newborn hearing screenings performed during the initial Texas Health Steps (THSteps) visit are considered part of the initial newborn medical check up and are not considered for reimbursement as separate procedures. Providers that are not THSteps-enrolled must refer the infant to an enrolled THSteps provider for an initial THSteps medical check up, which includes a newborn hearing screening. An initial newborn hearing screening for infants who are not admitted to a birthing facility consists of the following: Completing the Hearing Checklist for Parents form. Assessing any physical abnormalities. Instructing the parent(s) on the use of the hearing checklist. Informing the parent(s) of the results. Referring the high-risk infant to a physician who renders audiology services. 23.3.1.3 Outpatient Hearing Screening and Diagnostic Testing for Children As part of the THSteps medical check up, physicians are required to complete the hearing screening component. Separate procedure codes must not be billed when hearing screenings are part of medical check ups or day care/school requirements. Medicaid does not reimburse separately. For children who are seen in the office setting, THSteps requires a puretone audiometer for visits where objective screening is required. In other childcare settings (e.g., day care; preschool; Head Start; and elementary, middle, and high school), the DSHS Vision and Hearing Screening Program requires that a puretone audiometer be used for hearing screening. Impedance testing is usually used in the physician s office to monitor children who have a documented history of repeated bouts of otitis media and may be billed separately as a diagnostic hearing test with a THSteps check up. Impedance testing does not meet the requirements for the sensory screening component of the THSteps check up. 23 CPT only copyright 2007 American Medical Association. All rights reserved. 23 3
Section 23 23.3.1.4 Three Years of Age and Younger A hearing screening must be completed during each THSteps medical check up. A THSteps hearing screening consists of the following: An observation and history recording obtained from a responsible adult familiar with the child. Completion of the Hearing Checklist for Parents form. Referral of a high-risk child to a physician who renders audiology services. 23.3.1.5 Three Through 20 Years of Age For children 3 years through 20 years of age, physicians are required to complete the hearing screening during each THSteps medical check up as part of the check up. Medicaid will not consider the hearing screening for reimbursement separate from the check up. For children who are seen in the office setting, the THSteps program requires a pure tone audiometer at visits where objective screening is required. In other child-care settings, (e.g., day care; preschool; Head Start; elementary, middle, and high school), the TDH Vision and Hearing Screening Program requires that a pure tone audiometer be used for hearing screening. The provider should do the following: Assess children with a puretone audiometric hearing screen (1000, 2000, 4000 Hz) at 4 through 10 years of age. Perform a subjective hearing evaluation, to include client history and observation of the child for the ability to answer questions and follow directions at all other medical check ups where an audiometric screen is not required. Document the results of any school screening audiometric testing program in the 12 months preceding the medical check up. Refer any child or adolescent (preschool through twelfth grade) who does not respond to a 25 db tone at any frequency for a diagnostic hearing evaluation. 23.3.1.6 Abnormal Screening Results All abnormal hearing screenings for infants and children from 20 years of age and younger should be referred to a local Medicaid provider for follow-up. If the purpose is to determine permanent hearing loss or type of amplification needed, infants and children must be referred to an approved hearing services PACT provider for follow-up. Traditional Medicaid providers may be reimbursed for the follow-up care when a local PACT provider is not accessible. All abnormal hearing screenings for clients 21 years of age and older must be referred to a physician who provides audiological services. 23.3.1.7 Adults Hearing Screening 21 Years of Age and Older ABR and OAE audiometry are benefits of the Texas Medicaid Program for infants, children, and adults and may be used in addition to conventional audiometry for further diagnosis. 23.3.1.8 Hearing Referrals For clients 20 years of age and younger, providers should refer Medicaid-eligible children identified during the THSteps medical check up as needing a diagnostic hearing evaluation or other hearing services, including hearing aids, to an approved hearing services provider. DSHS provides payment to providers for hearing services provided to children eligible for Texas Medicaid Program services. Separate procedure codes may be billed for children who require diagnostic hearing testing. The following diagnostic audiometric testing codes may be billed as appropriate: 5/I-92567, 5/I/T-92585, 5-92586, 5/I/T-92587, and 5/I/T-92588. 23.3.2 Hearing Aid Instrument Medicaid reimbursement for hearing aid instruments is limited to eligible clients, 21 years of age and older, whose air conduction puretone average in the better ear is 45 db or greater. The client must have medical necessity for a hearing aid instrument and have no medical contraindications for using a hearing aid. Each client must be offered an appropriate new hearing aid instrument within the Medicaid allowable fee schedule. Hearing aid(s) are considered for reimbursement once every six years. Important: TMHP may refer people to the Texas Rehabilitation Commission whose jobs are contingent on possession of a hearing aid as well as people appearing to have vocational potential and who need a hearing aid. 23.3.2.1 Warranty Each hearing aid instrument dispensed through the Texas Medicaid Program must be a new and current model that meets the performance specifications indicated by the manufacturer and the client s individual hearing needs. A new hearing aid is one that has never been used and carries a full 12-month manufacturer s warranty. The manufacturer s warranty must be effective for 12 months after the dispensing date. 23.3.2.2 30-Day Trial Period Providers must allow each Medicaid client a 30-day trial period that gives the client time to determine satisfaction with a purchased hearing aid instrument. The trial period consists of 30 consecutive days beginning with the dispensing date. During the trial period, providers may dispense additional hearing aids as medically necessary until the client is satisfied with the results of the aid, or the provider determines that the client cannot benefit 23 4 CPT only copyright 2007 American Medical Association. All rights reserved.
Hearing Aid and Audiometric Evaluations from the dispensing of an additional hearing aid. A new trial period begins with the dispensing date of each hearing aid. Under the Texas Medicaid Program, if the client is not satisfied with the purchased hearing aid instrument, the client may return it to the provider, who must accept it. If the aid is returned within 30 days, the provider may charge the client a rental fee. Providers must obtain a client-signed acknowledgment statement stating the client is responsible for paying the hearing aid rental fees and retain the signed acknowledgment statement in the client s file. Client must sign the acknowledgment statement prior to receiving the hearing aid. Providers must allow 30 days to elapse from the hearing aid dispensing date before completing a 30-Day Trial Period Certification Statement. 23.3.2.3 Fitting and Dispensing Visit The fitting and dispensing visit also includes the postfitting check. 23.3.2.4 First Revisit Additional counseling is available as needed within a period of six months after the post-fitting check. The first revisit, 99211, includes a hearing aid check. 23.3.2.5 Second Revisit The second revisit procedure code 99212, includes aided sound field testing performed by a contracted evaluator according to the guidelines specified for the hearing evaluation. If the aided sound field test scores suggest a decrease in hearing acuity, the provider must include puretone and speech audiometry on Form 3503, Hearing Aid Evaluation Report. The second revisit is available as needed after the post-fitting check and the first revisit. The following table lists hearing aid instrument, assessment, and revisit procedure codes. Note: Hearing aid procedures indicated with "" must be submitted with the MSRP in the Comments field of the claim. If the MSRP is not included in the comments field on the original submission, the claim will be denied. Providers will be required to submit their request as an appeal, and must include an invoice validating the cost of the instrument. Procedure Code Medicaid Fee R-99211 * R-99212 * R-V5010 $44.35 R-V5011 $50.00 R-V5030 R-V5040 R-V5050 * Refer to the Physician Fee Schedule on the TMHP website at www.tmhp.com Procedure Code Medicaid Fee R-V5060 R-V5070 R-V5080 R-V5090 $100.00 R-V5100 R-V5110 $150.00 R-V5120 R-V5130 R-V5140 R-V5150 R-V5160 $170.00 R-V5170 R-V5180 R-V5190 R-V5200 $170.00 R-V5210 R-V5220 R-V5230 R-V5240 $170.00 R-V5241 $115.00 R-V5242 R-V5243 R-V5244 R-V5245 R-V5246 R-V5247 R-V5248 R-V5249 R-V5250 R-V5251 R-V5252 R-V5253 R-V5254 R-V5255 R-V5256 R-V5257 R-V5258 R-V5259 R-V5260 R-V5261 R-V5262 * Refer to the Physician Fee Schedule on the TMHP website at www.tmhp.com 23 CPT only copyright 2007 American Medical Association. All rights reserved. 23 5
Section 23 Procedure Code Medicaid Fee R-V5263 R-V5264 $18.90 R-V5265 $18.90 R-V5275 $18.90 R-V5298 R-V5299 * Refer to the Physician Fee Schedule on the TMHP website at www.tmhp.com 23.3.3 Audiological Testing Audiometry is the testing of a person s ability to hear various sound frequencies and is performed with the use of electronic equipment. Audiometry is used to identify and diagnose hearing loss. Air and bone pure tone audiometry threshold testing assesses air and bone conduction. Speech reception threshold (SRT) and word recognition tests indicate the softest level that a person is able to hear and repeat two-syllable words, and how well a person can repeat words presented at a comfortable listening level. Speech audiometry uses a series of simple recorded words spoken at various volumes into headphones worn by the person being tested. The person repeats each word back as it is heard. Procedure code 5-92557 is a comprehensive code. If any of the following procedure codes are submitted with the same date of service as procedure code 5-92557, they are denied as part of another service: Procedure Codes 5-92551 5-92552 5-92553 5-92555 5-92556 If three or more of the procedure codes listed above are submitted for reimbursement with the same date of service, they are denied with instructions to submit the appropriate audiometry procedure code (5-92557). Procedure codes 5-92563, 5-92567, 5-92568, and 5-92569 are diagnostic hearing procedures that may be considered for reimbursement separately. Tympanometry impedance testing (procedure code 5-92567) should never be used as the sole clinical means to establish the presence or absence of acute or chronic middle ear effusion or infection. Direct otoscopic examination by a suitably qualified provider, with or without pneumatic otoscopy, is the key element of the standard method used to establish a diagnosis of middle ear disease. Tympanometry must be limited to selected individual cases where its use demonstrably adds to the provider's ability to establish a diagnosis and provide appropriate treatment. Tympanometry is limited to four services per year by the same provider and is based on medical necessity. Medical necessity must be documented in the patient s medical record. Tympanometry does not meet the requirements for a sensory screening component of the THSteps medical check up. Acoustic reflex testing (procedure codes 5-92568 and 5-92569) provides information about the middle ear, specifically middle ear muscle reflexes in response to sound. The test can help distinguish between sensory (cochlear) hearing loss and neural (retro-cochlear) hearing loss. Acoustic reflex testing (procedure codes 5-92568 and 5-92569) is limited to the following diagnosis codes: Diagnosis Codes 2251 3510 3511 3518 3519 38600 38601 38602 38603 38604 38610 38611 38612 38619 3862 38630 38631 38632 38633 38634 38635 38640 38641 38642 38643 38648 38650 38651 38652 38653 38654 38655 38656 38658 3868 3869 3870 3871 3872 3878 3879 3882 38830 38831 38832 38840 38841 38842 38843 38844 38845 3885 38905 38906 38913 38915 38916 38917 38920 38921 38922 7443 7804 Evoked response testing includes the following procedures: ABR, also called brainstem evoked potential (BSER), audiometry is a procedure in which neural discharges from the auditory pathways are measured with surface electrodes situated on the scalp. Otoacoustic emissions (OAE) measures response from the cochlea. Procedure codes 5-92585, 5-92586, 5/I/T-92587, and 5/I/T-92588 may be submitted for evoked response testing. Each evoked potential test is considered a bilateral procedure. If separate charges are submitted for left- and right-sided tests of the same type, the tests will be combined and considered a quantity of one. An electroencephalogram (EEG) submitted with the same date of service as an evoked response test is considered for reimbursement at the full reimbursement rate. Evoked response testing is also considered for reimbursement at the full reimbursement rate. Procedure code 1-95920 is considered for reimbursement in addition to each evoked potential test. Procedure code 1-95920 is limited to a maximum of two hours each day, regardless of provider, without documentation of medical necessity. 23 6 CPT only copyright 2007 American Medical Association. All rights reserved.
Hearing Aid and Audiometric Evaluations 23.4 Limitations and Exclusions The following limitations and exclusions apply: Reimbursement for a hearing aid instrument is limited to eligible clients, 21 years of age and older, whose air conduction puretone average in the better ear is 45 db or greater. Hearing aid purchases are limited to one every six years with the exception of clients birth through 20 years of age through PACT. Clients birth through 20 years of age must be referred to PACT. Services for residents in nursing facilities (skilled nursing facility [SNF], intermediate care facility [ICF], or extended care facility [ECF]) must be ordered by the attending physician. The order must be on the client s chart and state the condition necessitating hearing aid services and must be signed by the attending physician. No payment is made for replacement of batteries or cords. No payment is made for repairs or replacements of lost, destroyed, or inappropriate hearing aids. No binaural fittings are available except in certain documented cases of legally blind, hearing-impaired clients who have no other available resources. This information must be documented in the client s file as well as on the claim submitted for payment for hearing aid services. U.S.-manufactured hearing aids must be considered when the purchase price and quality are comparable to those of foreign manufacturers. Home visit hearing evaluations and fittings are permitted only with the physician s written recommendation. Auditory training, speech, reading, or other rehabilitative services are not included. Refer to: CMS-1500 Claim Filing Instructions on page 5-22. 23.5 Documentation Requirements TMHP does not require prior authorization for hearing aids and related procedures. Retain reported audiological and medical information in the client s file until requested. The hearing evaluation must be recommended by a physician (with written medical clearance) for the fitting of a hearing aid by completing the Physician s Examination Report. The Hearing Aid Evaluation Report must include an audiometric assessment. This form must provide objective documentation to support improved communication ability with amplification. Refer to: Physician s Examination Report on page B-71. Hearing Evaluation, Fitting, and Dispensing Report (Form 3503) on page B-41. 23.6 Client Eligibility The provider determines a client s eligibility for hearing aid services by any of the following: Asking to see the client s current Medicaid eligibility form (possession of a current Medicaid eligibility form with a check mark in the hearing aid box indicates the client s eligibility for the month). Using the Automated Inquiry System (AIS) to determine eligibility for Medicaid and for a hearing aid. Verifying client eligibility on the TMHP website at www.tmhp.com. Important: AIS provides claim status, client eligibility, benefit limitations, and current check amount. Refer to: Eligibility Verification on page 4-4. Automated Inquiry System (AIS) on page -xiii for instructions or contact TMHP Customer Service at 1-800-925-9126. 23.7 Claims Information Hearing aid services must be submitted to TMHP in an approved electronic format or on the CMS-1500 claim form. Providers may purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements. Providers supplying hearing aids for STAR+PLUS Medicaid Qualified Medicare beneficiary (MQMB) clients should submit claims to TMHP, not the STAR+PLUS HMO for the hearing aid. Refer to: TMHP Electronic Data Interchange (EDI) on page 3-1 for information on electronic claims submissions. Claims Filing on page 5-1 for general information about claims filing. CMS-1500 Claim Filing Instructions on page 5-22. Blocks that are not referenced are not required for processing by TMHP and may be left blank. 23 CPT only copyright 2007 American Medical Association. All rights reserved. 23 7
Section 23 23.7.1 Claim Filing Resources Refer to the following sections and/or forms when filing claims: Resource Page Number Automated Inquiry System (AIS) xiii TMHP Electronic Data Interchange 3-1 (EDI) CMS-Claims Filing Instructions 5-22 Communication Guide A-1 Hearing Evaluation, Fitting, and B-41 Dispensing Report (Form 3503) Physician s Examiniation Report B-71 Hearing Aid Assessments Claim D-15 Example Acronym Dictionary F-1 23 8 CPT only copyright 2007 American Medical Association. All rights reserved.